Q: Cognitive Problems or Mood Disturbances as the Deciding Factor
in Diagnosing BP?

back before i was diagnosed as bipolar (in high school) i used to
have delusions that i was alternately jesus christ or the devil. i have told my
doctors this, and as far as i can tell from my research, that is one of the main
characteristics that differentiates bipolar I from bipolar II, yet i have always
been listed as bipolar II. my doctors have told me that this is because i am a
rapidian cycler and tend towards somewhat dangerous mixed states rather than a
pure depression or mania. which is the deciding factor in diagnosing, the
cognative problems such as the delusions, or the mood disturbances such as
mixed-mania?

Dear Alex --
That's a sophisticated question. In my view, it's more sophisticated than the
diagnostic distinction allows. There is some evidence that bipolar II "breeds
true", i.e. that in a family, bipolar disorder is likely to stay either Bipolar
I or Bipolar II. So in that sense, there may really be a biological
basis for the distinction.

However, your question points out the rather vague
territory on the "border" between BPI and BPII. I'm not very confident of
making a distinction between the two in a way that really matches what we might
guess is the underlying biology of the conditions. The easiest "cut point" is
the presence of delusions: that is by definition "psychosis", and by definition
that's supposed to be Bipolar I. You clearly understand this and that's why
you're asking your question, I understand.

Your doctors are instead emphasizing the mixed
state/rapid cycling aspect of your version of bipolar disorder. I'm not so sure
that really means one should be thinking in "bipolar II" terms, to capture this
aspect. To my understanding of the DSM, the rule book for all this, one can
certainly have rapid cycling and mixed states in Bipolar I. However, I'd agree
with your doctors that those phenomena are more characteristic of BPII, in the
main.

But, except for trying to capture something that might
really go along with that underlying biology, though, there's not much point in
trying to distinguish between I and II. The treatment is clearly the same
(except that some doctors would emphasize using antipsychotics in BP I; I'm less
swayed by the presence of "psychosis" in making that choice than some of my
colleagues, and as a result I might undertreat the psychosis part sometimes, but
the trade-off is that I think I might be using medications that are more
specifically targeted at the core problem -- and less problematic in terms of
side effects, I hope).